TB Free in the University and College Setting · TB Free in the University and College Setting Curry International Tuberculosis Center University of California, San Francisco 4 Course

TB Free in the University and College Setting

Curry International Tuberculosis CenterUniversity of California, San Francisco 1


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Curry International TB Center (CITC)

Tuberculosis Centers of Excellence for Training, Education, and Medical Consultation (TB COE)

Areas of Coverage, 2018

Project Funding

This training was funded by the Centers for Disease Control and Prevention's Cooperative Agreement 1NU52PS910163-01 and is a project of the University of California, San Francisco (UCSF)

The views expressed in written materials and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services, nor does the mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government



Course Credit

This webinar is approved for a total of 1.25 continuing education contact hours for doctors and nurses.

Course Credit (2)

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CertificatesThe Curry International Tuberculosis Center is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This training is approved for up to 1.25 continuing education hours.

The Curry International Tuberculosis Center designates this educational activity for a maximum of 1.25 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The Curry International Tuberculosis Center is approved as a provider of continuing education by the California State Board of Registered Nurses, Provider Number CEP 12308. This training is approved for 1.25 continuing education hours. Board requirements prevent us from offering CE credit to people who arrive more than 15 minutes after the start of the training, or leave the training early. Therefore, partial credit will not be awarded.

Certificates will be available on the Curry International Tuberculosis Center website approximately twelve weeks after the training to all participants who requested CME or nursing credits on their applications and who successfully complete the training. To view your certificate you will need to go to the training page, log in and click on “training history.”

8

Declaration of Disclosure

The following webinar faculty have indicated that they do not have a financial relationship or conflict of interest with any commercial interest that may have a direct bearing on the subject matter:

• Jenny Flood, MD, MPH

• James Koski, MD, MPH

• Heidi Behm, RN, MPH

• Monica Pecha, MPH

The following faculty member has indicated that he may present information on investigational or off-label use of pharmaceutical or medical devices:

• James Jacobs, MD, PhD



Webinar Agenda

12:00 – 12:05 Introduction and OverviewAmelia Alonis

12:05 – 12:15 Opportunities for TB Prevention in College StudentsJenny Flood, MD, MPH

12:15 – 12:20 ACHA Guidelines: Overview and UpdatesJames Jacobs, MD, PhD

12:20 – 12:50 TB Free in the University and College SettingJames Koski, MD, MPH

12:50 – 1:15 Q & AFaculty

Today’s Faculty

Jenny Flood, MD, MPH

TB Control Program Officer/Chief, TB Control BranchDivision of Communicable Diseases

ControlCenter for Infectious DiseasesCalifornia Department of Public HealthRichmond, CA



Opportunities for TB Prevention in College Students

Jenny Flood, MD, MPHTuberculosis Control Branch

California Department of Public HealthDecember 6, 2018

OREGON STATE UNIVERSITY 13

Objective 1:

Identify key populations at risk for TB infection and TB disease based on current epidemiology data and use this information to prioritize these populations for testing and treatment



Young adults with TB in U.S.

• 18 year old who arrived from Guatemala 3 years previously

• Presents with fever and cough to ER

• Bronchitis diagnosed

• Returned to ER with massive hemoptysis

• 22 year old in U.S. since college entry

• TB in lymph nodes around his airway

• With treatment lymph nodes may get larger before resolving

Q. “Is there anything I could have done to prevent this from happening?”

What is the frequency of TB disease and infection in individuals of college age?

15



16

17

International Students at U.S. Colleges & Universities



18

Places of Origin for International Students

Overseas Screening Requirement

NO TB screening is required for the following groups:▪ Visitor/tourist

▪Student▪ Work

▪ Unauthorized (undocumented)

Required for:▪ Immigrant

▪ Refugees

▪ Permanent resident applicants

▪ Asylees

▪ Status adjusters



TB Disease in Persons Ages 18-24 in U.S.

20

Cases Incidence

Total 878 2.8/100,000

US-born 629 0.9/100,000

Non-US-born 249 18.8/100,000

• Overall: 2.82 per 100,000

• Born in the U.S.: 0.9 per 100,000

• Born outside the U.S.: 18.8 per 100,000

TB Exposures on College Campuses in U.S.

~ 900 TB cases in 18-24 year olds translates to:

• Potential for ~1 TB exposure every day on a college campus in U.S.



Latent TB Infection in 18-24 year olds, U.S. 2011

22

Most are unaware of their TB infection and untreated!

IGRA positive

US-born 1.3%

Foreign-born 8.7%

________________________________

Total 2.5%

~ 800,000 young adults

Source:

Estimated using NHANES and 2011 census data

Who should be tested?

• User-friendly, simple tool piloted extensively

California TB Risk Assessment

• Testing these groups can prevent > 90% of TB cases

• Points clinicians to 3 main groups at risk for TB

j

Birth, travel, or residence in a country with an elevated TB rate for at

least 1 month

• Includes any country other than the United States, Canada, Australia, New Zealand, or a country in

western or northern Europe

k

Immunosuppression, current or planned

HIV infection, organ transplant recipient, treated with TNF-alpha antagonist, steroids or other immunosuppressive medicationl

Close contact to someone with infectious TB disease during lifetime



Summary

• Universities/colleges have growing number of international students

• TB among students is a frequent occurrence and resource intensive

• New USPSTF recommendations call for TB screening in adults who are born outside US

• College entry provides opportunity for TB prevention

• LTBI testing followed by LTBI treatment can prevent TB disease



Today’s Faculty

James Jacobs, MD, PhD

Chair-Elect of the Emerging Public Health Threats and Emergency Response Coalition

American College Health Association

Executive Director, Vaden Health Center

Stanford UniversityPalo Alto, CA

ACHA Guidelines:Overview and Updates

James Jacobs, MD, PhD

Stanford University




Objective 2:

Describe the current ACHA guidelines for “TB Screening and Targeted Testing of College and University Students” and utilize this information to improve patient outcomes in this population

ACHA guidelines: Tuberculosis screening and targeted testing of college and university students

• TB screening: TB screening for all students

▶Recommends screening at time of admission

▶Questionnaire identifies higher risk persons

• Targeted TB testing: TB testing of high risk students

only

▶IGRA preferred in international students

▶If positive, chest x-ray to determine if LTBI

• LTBI treatment: Recommended for all persons with

LTBI

▶Higher priority if high risk of progression


https://www.acha.org/documents/resources/guidelines/ACHA_Tuberculosis_Screening_2017.pdf



Today’s Faculty

James Koski, MD, MPH

Internal Medicine PhysicianOregon State University, Student

Health ServicesCorvallis, OR

TB FREE IN THE UNIVERSITY AND COLLEGE SETTING

James Koski, MD, MPH OSU Student Health Services




Objective 3: Identify the essential components of an effective TB screening & LTBI treatment program in the college and university setting to inform clinical decision-making and enhance patient care

Latent TB Infection (LTBI) vs TB Disease

*From the CDC website pdf: ”TB Elimination– The Difference Between Latent TB Infection and TB Disease

Person with Latent TB Infection Person with TB Disease

TB screening test (TST or IGRA): abnormal TB screening test (TST or IGRA): typically abnormal

Chest x-ray: Normal Chest x-ray: Typically abnormal or positive sputum smear/culture

TB bacteria: Live but inactive TB bacteria: Active

Asymptomatic Symptomatic: coughing, fever, night sweats, weight loss

Non-infectious Infectious




Oregon State University experience

•35 years of international student TB screening

•2010-2016: ▶60% of Benton County TB cases (9/15) were OSU

students▶56 % increase in international student enrollment

•2016-2018: ▶~ 31,000 total enrollment▶~ 11.0 % (~ 3,400) international students▶~ 28.0 % (~ 950) international students/year test with

IGRA (QFT-G)▶~ 4.5 % LTBI prevalence rate


OSU TB Screening Team

• Brittney Holcomb, MA, Immunization/TB Compliance Manager

• Mark Hornabrook, MT (ASCP), SBB, MHA, Laboratory Director▶Leslie Kaye, LMT2, TB screening tracking coordinator

• Charmaine Abrams, RT(R), X-ray Manager

• Patti Irvine, RN, Nursing Clinical Manager▶Lynn Ward, RN, Nurse counselor

• Jennifer Davis, PharmD, Director of OSU Pharmacy▶Jackie Foster, PharmD, Clinical Pharmacist▶Sierra Carpenter, PharmD, Pharmacy resident

• James Koski, MD, MPH, OSU TB Physician




Identifying Who Needs TB Testing

• International students from

▶Higher TB endemic countries with WHO TB incidence rate of

greater to or equal to 20 cases/100,000.

• Domestic students with

▶Birth, travel, or residence in a country with an elevated TB rate

for at least 1 month.

• All students with

▶Immunosuppression, current, or planned

▶Close contact to someone with infectious TB disease during

lifetime


TB screening clinics

• Immunization/TB screening clinic: new student orientation▶Immunizations

• Required: MMR, HepB, Varicella, MCV4, Tdap

▶TB screening • TB screening questionnaire

• Screening IGRA blood test (QFT-G) if from country of high incidence (20 cases/100,000)

• Follow-up TB screening clinic if positive IGRA test▶1V chest x-ray and initial LTBI counseling

▶Referrals: pharmacy for LTBI treatment or TB physician for secondary counseling


https://studenthealth.oregonstate.edu/infectious-diseases/tuberculosis/countries-high-tuberculosis-incidence

https://studenthealth.oregonstate.edu/sites/studenthealth.oregonstate.edu/files/intl_hhx_20181129.pdf



Non-compliance with screening and counseling = REGISTRATION HOLD

• SHS monitors student compliance with health policies.

• Failure to provide completed health history form, proof of required immunizations or completed TB testing (if required) before pre-registration period for next term's classes: SHS enters code in Student Information System preventing registration.

• Students can monitor holds via Student Online Services > Student Records > View Holds and can call Immunization Helpline (541-737-7573) or come to SHS to find out why they have a hold and how to have it removed.


Financing the Screening Program

2018 Student Costs

• Mandatory student health fee per term: $165.71▶Funds student health staffing

• Mandatory health insurance per term: $745.60

• TB screening tests- 20% insurance co-pay▶IGRA Test: avg. student cost $20.00▶1V Chest x-ray: avg. student cost $21.40

• LTBI treatment costs: 20% insurance co-pay▶3 month Isoniazid/Priftin (Rifapentine) (3HP): avg. student cost

$80▶4 month Rifampin (4R): avg. student cost $50▶9 month Isoniazid (9H): avg. student cost $35


https://studenthealth.oregonstate.edu/sites/studenthealth.oregonstate.edu/files/intl_hhx_20180725.pdf

https://studenthealth.oregonstate.edu/infectious-diseases/tuberculosis/countries-high-tuberculosis-incidence



Utilizing a Tracking Coordinator

• Tracks IGRA + patients through:▶TB Screening

▶LTBI counseling

▶LTBI treatment

• Tracking coordinator can be:▶Nursing staff vs. laboratory staff vs. clinical pharmacist

• Utilize Excel spreadsheet to track positive patients throughout screening, counseling and treatment


Counseling Tools

• CDC Stop TB poster

• CDC fact sheets: LTBI treatment

• Language-specific handouts and access to language line translators

• BCG World Atlas

• Online TST/IGRA Calculator ▶Risk of Exposure & Risk of Progression

• OSU Mantra: “Decision to test is a decision to treat”

• Flexibility: Postpone treatment a term, until summer, a year later


https://www.cdc.gov/tb/publications/posters/stoptb.htm

https://www.cdc.gov/tb/publications/factsheets/treatment.htm

https://www.oregon.gov/oha/PH/DISEASESCONDITIONS/COMMUNICABLEDISEASE/TUBERCULOSIS/Pages/factsheets.aspx

http://www.bcgatlas.org/

http://www.tstin3d.com/



Importance of Repeated Counseling


Role of Pharmacy

• Counseling regarding LTBI treatment options

• Initiating and monitoring treatment ▶3HP Directly Observed Therapy (DOT): weekly visits

▶4R & 9H: monthly visits

• Collaborative care with TB physician▶Communicate and consult with TB physician on regular basis

• Completion letters and documents▶Provide completion letter

▶IGRA test result, chest x-ray report, & digital x-ray




Objective 4:Explain the different LTBI treatment options in order to optimize patient care


Update of Recommendation for Use of Once-Weekly Isoniazid-Rifapentine Regimen to Treat Latent Mycobacterium Tuberculosis infection

MMWR Morb Mortal Wkly Rep. 2018 June 29;67(25):723-726

• 3HP: safe, effective, higher treatment completion rates.

• 3HP is now recommended▶in persons with LTBI aged 2-17

▶in person with LTBI who have HIV infection including AIDS and are taking antiretroviral medications with acceptable drug-drug interactions with rifapentine.

▶by DOT or self-administered therapy (SAT) in persons age >2 years.




Four Months of Rifampin or Nine Months of Isoniazid for Latent Tuberculosis in Adults

N Engl J Med 2018;379:440-53

Conclusions:▶4-month regimen of rifampin not inferior to a 9-month regimen of INH for prevention of active tuberculosis.

▶Rifampin (4R) compared to INH (9H):• significantly higher rate of treatment completion by +15 % (INH

63% vs RIF 78%).

• fewer serious drug related events: -1.1 % for all adverse events and by -1.2 % for hepatotoxicity.


Comparison of LTBI treatment regimens

Regimen 3HP 4R 9H

Duration 3 month 4 months 9 months

Dosage INH 15 mg/kg (900 max)RIF weight based dosing

10mg/kg (600 max.) 5mg/kg (300 max)

Number of Doses 12 weekly doses 120 daily doses 270 daily doses

Avg. Number of pills 9 pills + vitamin B6 2 pills 1 pill + vitamin B6

Cost- Cash/Patient $377/$80 $199/$50 $149/$35

Number of visits 12 weekly visits 4 monthly visits 9 monthly visits

Potential Side Effects Rash, GI side effects, Hepatitis, , hematologic,Peripheral NeuropathyColored Secretions

Rash, GI side effects,Hepatitis, Hematologic

Colored secretions

Rash, GI Side EffectsHepatitis, Peripheral Neuropathy

Considerations Avoid in pregnancyDrug interactions- OCPAvoid alcohol

Avoid in pregnancyDrug interactions- OCPAvoid alcohol

OK in pregnancy

Avoid alcohol




OSU Initiation Rate (IR) for LTBI Treatment

2015-2016 2016-2017 2017-2018

Initiation Rate (IR) 35.2 % (19/54) 71.1 % (27/38) 69.8 % (27/39)

Decline Treatment 25.9 % (14/54) 21.0 % (8/38) 30.8 % (12/39)

Undecided 0.0 % (0/0) 0.0 % (0/0) 0.0 % (0/0)

Lost to Follow-Up 38.9 % (21/54) 7.9 % (3/38) 0.0 % (0/0)


Patient preference for LTBI regimens

LTBI Regimen 2015-2016 2016-2017 2017-2018

3HP 68.4 % (13/19) 70.4 % (19/27) 59.3 % (16/27)

9H 31.6 % (6/19) 29.6 % (8/27) 29.6 % (8/27)

4R Not offered Not Offered 11.1 % (3/27)

LTBI Regimen 2015-2016 2016-2017 2017-2018 Average Total

3HP 84.6 % (11/13) 94.7 % (18/19) 93.8 % (15/16) 91.7 % (44/48)

9H 83.3 % (5/6) 75.0 % (6/8) 100.0 % (8/8) 86.4 % (19/22)

4R Not offered Not offered 100.0 % (3/3) 100.0 % (3/3)

Completion rates (CR) for LTBI regimens




In summary . . .

• Create at TB Screening Team & Champion Provider

• Implement TB Risk Assessment Questionnaire/Tools

• Targeted TB Testing for Higher Risk Persons

• Mandatory screening/counseling tied to registration

• Utilize counseling tools & require repeated counseling

• “A decision to test is a decision to treat”

• Offer shorter treatment regimens: 3HP and 4R


TB Centers of Excellence forTraining, Education and Medical Consultation

•Curry International Tuberculosis Center

•Global Institute at Rutgers, The State University New Jersey

•Heartland National Tuberculosis Center▶Model TB Prevention Program for College Campuses

•Southeastern National Tuberculosis Center


http://www.currytbcenter.ucsf.edu/

http://globaltb.njms.rutgers.edu/

http://www.heartlandntbc.org/

https://dph.georgia.gov/sites/dph.georgia.gov/files/TB-Pub_Sch_modelcollege_campuses.pdf

https://sntc.medicine.ufl.edu/home/index#/



Additional submitted questions


Presenters and Panelists

Heidi Behm, RN, MPH

Tuberculosis Controller/ Nurse Consultant

Public Health Division, Oregon Health Authority

Portland, OR

Monica Pecha, MPH

Tuberculosis Controller/ Program Manager

Disease Control and Health Statistics

WA State Department of Health

Shoreline, WA

Jenny Flood, MD, MPHTB Control Program Officer/

Chief, TB Control Branch

Division of Communicable Diseases Control

Center for Infectious Diseases

California Department of Public HealthRichmond, CA

James Jacobs, MD, PhDChair-Elect of the Emerging Public

Health Threats and Emergency Response Coalition




James Koski, MD, MPHInternal Medicine Physician

Oregon State University, Student Health Services

Corvallis, OR



How do you follow up with students who have latent TB but refuse treatment? Yearly TB symptom risk assessment? Chest x-ray?


Are there statistics on LTBI treatment success rates?

Are there different rates of cure?




Should foreign students be screened if they are only in the U.S. for one semester and completion of LTBI tx would not be possible?


IGRAs in screening of both high-risk and low-risk students? False positives?




“If I get LTBI treatment, what happens when I go back to my country? Will I be exposed again? Will I have to complete treatment again?”


Do you re-test if someone is going to their home country for the summer?

Do you test students that study abroad?




Small campuses or community colleges –medical personnel not available on campus – what resources are available to me? Where can I seek help on a strategy?


Questions?????

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Presenters and Panelists

Heidi Behm, RN, MPH

Tuberculosis Controller/ Nurse Consultant

Public Health Division, Oregon Health Authority

Portland, OR

Monica Pecha, MPH

Tuberculosis Controller/ Program Manager

Disease Control and Health Statistics

WA State Department of Health

Shoreline, WA

Jenny Flood, MD, MPHTB Control Program Officer/

Chief, TB Control Branch

Division of Communicable Diseases Control

Center for Infectious Diseases

California Department of Public HealthRichmond, CA

James Jacobs, MD, PhDChair-Elect of the Emerging Public

Health Threats and Emergency Response Coalition




James Koski, MD, MPHInternal Medicine Physician

Oregon State University, Student Health Services

Corvallis, OR

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Contact Information

Curry International Tuberculosis CenterUniversity of California, San Francisco

300 Frank Ogawa Plaza, Suite 520Oakland, CA 94612

(510) 238-5100

www.currytbcenter.ucsf.edu

[email protected]

for joining today’s webinar

Documents

TB Free in the University and College Setting · TB Free in the University and College Setting Curry International Tuberculosis Center University of California, San Francisco 4 Course